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08-05-14 (2)
r t 1 1505610105 �1 REV-1500 EX(a3-n) n,� . OFFICIAL USE ONLY PA Department of Revenue pennsytvanda Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN Harrisburg,PA 17128-o6oi RESIDENT DECEDENT a ! ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 11/25/2013 06/0711926 Decedent's Last Name Suffix Decedent's First Name MI HALL EDNA G (if Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW M 1.Original Return O 2.Supplemental Return O 3. Remainder Return(Date of Death Prior to 12-13-82) O 4.Limited Estate O 4a. Future Interest Compromise(date of Q 5. Federal Estate Tax Return Required death after 12-12-82) Op 6. Decedent Died Testate Q 7. Decedent Maintained a Living Trust 4 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11, Election to Tax under Sec.9113(A) Between 12.31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED,ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number KRISTINE MINER (717)258-1749 REGISTER OF WILLS USE ONLY, First Line of Address pDv"7 i= G? ? 1329 SWOPS ROAD r I ul r7 C Second Line of Address ..._ ._ C-)C,, c- � c City or Post Office State ZIP Code CATtEFOlHO f,-,) C_,)BOILING SPRINGS PA 17007 rJ Correspondent's e-mail address: Under per iies of perjury,I declare that t have examined this return,inciudirg accompanying schedules and statements,and to the best of my e-iowledge and belief, it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge, SIGNA E OF P R d RESPQgi L; FOR FILING RETURN r DgTE ^ ADDRESS 1329 SWOPE ROAD, BOILING SPRINGS, PA 1700077 /J SIGNAN➢Ft�O�A1PARERiHER THANC�ESENTm ��,^'I (,�Y OAT iS ' ADDRESS r 11,, 3600 TRINDLE ROAD, CAMP HILL, PA 17011 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 J J 1505610205 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: HALL, EDNA RECAPITULATION 1. Real Estate(Schedule A). . .. .. .... ... 1, 150,350.00 2. Stocks and Bonds(Schedule B) ....................................... 2. 0.00 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) . ... 3. 0.00 . 4. Mortgages and Notes Receivable Schedule D 4. 0.00 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 169,021.17 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. 0.00 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested.. ...... 7, 0.00 8. Total Gross Assets(total Lines 1 through 7)............................. 8. 319,371.17 9, Funeral Expenses and Administrative Costs(Schedule H).. ... ............. . 9. 8,206.96 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............... 10. 2,609.85 11. Total Deductions(total Lines 9 and 10).. .. .... . .... .. 11. 10,816.81 12. Net Value of Estate(Line 8 minus Line 11)............................. 12. 308,554.36 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) ... ... .. ...... .. ...... . 13. 0.00 14. Net Value Subject to Tax(Une 12 minus Line 13) ........................ 14. 308,554.36 TAX CALCULATION•SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)X.0_ 15. 16. Amount of Line 14 taxable at lineal rate X.0 45 308,554.36 16. . 13,884.95 17. Amount of Line 14 taxable at sibling rate X.12 17. 18. Amount of Line 14 taxable at collateral rate X.15 18. 19. TAX DUE,_......... ...... .... .. 13,884.95 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Cr Side 2 1505610205 1505610205 1 S REV-1546 EX(Fi) Page 3 File Number Decedent's Complete Address: DECEDENTS NAME EDNA G. HALL STREETADDRESS 129 LOCUST ST CITY STATE ZIP SHIREMANSTOWN PA 17011 Tax Payments and Credits: 1, Tax Due(Page 2,Line 19) (1) 13,884.95 2, CreditslPayments A.Prior Payments B.Discount Total Credits(A+8) (2) 1 Interest (3) 4. If Line 2 is greater than Line 1+Line 3,enter the difference. This is the OVERPAYMENT. FIII In oval on Page 2,Line 20 to request a refund. (4) 5. 0 Lice 1+Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 13,884.95 Make check payable to REGISTER OF WILLS,AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X"IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred.......................................................................................... ❑ b. retain the right to designate who shall use the property transferred or its income----........................ ........ ❑ c, retain a reversionary interest...............................................................................--......._...........---..........._... ❑ d. receive the promise for life of either payments,benefits or care?........................-............................................ ❑ 2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death without receiving adequate conskleratron?................_...................„.... -..._-......................--.........,...............,... ❑ a 3. Did decedent own an'in trust for'or payable-upon-death bank account or security at his or her death?.............. ❑ 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation? ._................--........................................................._......._......__.............„.... ❑ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1,1994,and before Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent(72 P.S.§9116(a)(1.1)(i)I. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent (72 P.S.§9116(a)(1.1)(ii)).The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an adoptive parent or a stepparent of the child is 0 percent(72 P.S.§9116(a)(1.2)1. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in(72 P.S.§9116(a)(1)I. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent 172 P.S.§9116(a)(1.3)1 A sibling is defined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. �f REV-15DZ EX+(12-12) �pennsylvania SCHEDULE A �.�1 DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF: FILE NUMBER: HALL, EDNA G. 21-13-1275 All real property owned solely or as a tenant in common must be reported at fair market value,Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts, Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1. RESIDENCE LOCATED AT 129 LOCUST ST.,SHIREMANSTOWN,PA 17011 150,350.00 TOTAL(Also enter on Line 1,Recapitulation.) $ 150,350.00 If more space is needed,use additional sheets of paper of the same size. l I REV-1508 EX+(O&U) Q-.pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: HALL, EDNA G. 21-13-1275 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1, PERSHING BROKERAGE ACCOUNT 131,348.67 2, POSTMARK CREDIT UNION 8,594.00 1 M&T BANK 19,839.50 4, 2013 FEDERAL INCOME TAX REFUND 792.00 5. 2005 CHRYSLER SEBRING 4,050.00 6, PERSONAL POSSESSIONS 4,397.00 TOTAL(Also enter on tine 5, Recapitulation) $ 169,021.17 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+ (08.13) J pennsylvania SCHEDULE H 'I '' DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE Of FILE NUMBER HALL, EDNA G. 21-13-1275 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. MUSSELMAN FUNERAL HOME&CREMATION SERVICES 2,165.00 2. ANTIQUE MARKETPLACE OF LEMOYNE-URN 121.64 3. GINGRICH MEMORIALS 175.00 4. CONTE PHOTOGRAPHY-PHOTO MEMORIAL SERVICE 71.02 5. ST.JOHN'S LUTHERAN CHURCH-MEMORIAL SERVICE 237.10 6, PASTOR AND ORGANIST-MEMORIAL SERVICE 200.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Names)of Personal Representative(s) Street Address , City State^ZIP Year(s)Commission Paid: 2. Attorney Fees: 2,147.45 3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.) Claimant Street Address City State—ZIP Relationship of Claimant to Decedent 4. Probate Fees: 408.50 5. Accountant Fees: 6. Tax Return Preparer Fees: 1,111.25 7. EIRICKER'S AUCTION-AUCTIONEER EXPENSES TO SELL PERSONAL POSSESSIONS 1,270.00 8. NORTH MOUNTAIN APPRAISALS, INC 300.00 TOTAL(Also enter on Line 9, Recapitulation) $ 8,206.96 If more space is needed,use additional sheets of paper of the same size. REV-1512 E%+{12-12) 117pennsytvania SCHEDULE I �? DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES St LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER HALL, EDNA G. 21-13.1275 Report debts Incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION Of DEATH 1. TRANSPORT TO HOSPITAL 220.00 2. WEST SHORE WINDOW AND DOOR-BALANCE DUE 851.00 3. PPL BILL DATED 11/23/2013 87.84 4. VERIZON BILL DATED 11/161'2013 158.89 5. UGI BILL DATED 11/27/2013 124.17 6. TRI-COUNTY ANIMAL HOSPITAL-VETERINARIAN SERVICE FOR CAT 237.48 7. QUANTUM IMAGING AND THERAPEUTIC ASSOC,-MEDICAL EXPENSE 1318 8. QUILT WORK 289.38 9, ENCOMPASS INS CO OF AMERICA-HOME OWNERS INSURANCE 11116 10. PA AMERICAN WATER CO BILL DATED 12/912013 60.39 11. PA AMERICAN WATER BILL DATED 1111112013 34.51 12. ZIMMERMAN'S LANDSCAPING INVOICE#111316 225.00 13, POSTMARK CREDIT UNION VISA-STATEMENT DATED 1218/2013 106.85 14. UGI-WORK ORDER 293852-REPAIRED HOT WATER HEATER 89.00 TOTAL(Also enter on Une 10,Recapitulation) # 2,609.85 If more space is needed,insert additional sheets of the same size. a REV-113—X+(01-10) pennsylvania SCHEDULE ] DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: HALL, EDNA G. 21-13-1275 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under Sec.9116(a)(1.2).] I. KRISTINE MINER,1329 SWOPE RD.,BOILING SPRINGS,PA17007 DAUGHTER 70% 2. R MARSHALL HALL, 1421 CLEAR BROOKS DR,SIGNAL MT,TN37377 SON 30% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed,use additional sheets of paper of the same size. LAST WILL AND TESTAMENT OF EDNA G. HALL I, EDNA G.HALL,now domiciled in Cumberland County, Pennsylvania, declare this to be my Last Will. I revoke all other Wills and Codicils that I may have previously made. Article I My just debts and expenses of my last illness, funeral, and administration of my estate shall be paid by my Executor from the principal of my residuary estate as soon as practicable after my death. Article II All inheritance, estate, and succession taxes(including interest and penalties thereon,but not including any generation skipping tax) payable by reason of my death shall be paid out of and be charged generally against the principal of my residuary estate without reimbursement from any person. This provision is not a waiver of any right which my Executor has to claim reimbursement for any such taxes which become payable as the result of any property over which I have the power of appointment. Article HI I give, devise and bequeath my tangible personal property in accordance with any memorandum which I have handwritten or signed, located with my will or with my valuable papers and found within 30 days of the probate of my will. Gifts may only be to persons who survive me or to organizations which exist at my death, and if there is a conflict, the memorandum having the latest date shall govern. To the extent no such memorandum is found, or all of my tangible personal property is not disposed of pursuant thereto, my tangible personal property shall be added to my residuary estate and pass under Article IV hereof. Article IV All the rest,residue and remainder of my estate, of whatsoever nature and wheresoever situate,I give, devise and bequeath as follows: (a) Seventy percent(70%)of my estate shall be paid to my daughter, KRISTINE E. MINER, of Cumberland County,Pennsylvania;and (b) Thirty percent(30%) of my estate shall be paid to my son, R.MARSHALL HALL, of Chattanooga,Tennessee. However, if a beneficiary does not survive me by thirty(30) days, but leaves descendants who survive me by thirty (30) days, those descendants shall receive, per stirpes, the share the beneficiary would have received had he or she survived me by thirty(30)days. Article V It is my intent that all life insurance, annuities, individual retirement accounts and any other assets in which I may designate a beneficiary will pass to the beneficiary that I have named and will not be controlled by the provisions of this Will. It is also my intent that any assets I own jointly with another with rights of survivorship or a presumed right to survivorship which such -2- joint ownership was created before or after this Will,will pass to the surviving joint owner and will not be controlled by the provisions of this Will. Article VI If a beneficiary under this Will has not attained the age of twenty-one (21) years, the share of the beneficiary shall be placed in a separate trust, for the benefit of that beneficiary according to the terms in Article VII. Article V11 In the event that a Trust is created by or as a result of any part of this Will, the terms and conditions of the Trust shall be as follows: A. To expend and apply so much of the net income and so much of the principal of the Trust as the Trustee shall consider advisable for the support,health, care and education of the child until the child attains the age of twenty-one(2 1) years. B. Upon attaining the age of twenty-one (21), the remaining principal and accumulated income of the child's share shall be distributed outright to the child. C. No beneficiary or remainderman of this Trust shall have any right to alienate, encumber, or hypothecate his or her interest in the principal or income of the Trust in any manner, nor shall any interest be subject to claims of his or her creditors or liable to attachment, execution,or other processes of law. D. At the time any distribution or distributive share of Trust assets is to be made by the Trustee, if a beneficiary of this Trust is disabled as defined in Section 1614(a)(3) of the Social Security Act (as determined by the Social Security Administration or by any State-level -3- i disability determination agency operating under the auspices of the Social Security Administration), and/or has been determined by a nursing home or State agency to be medically eligible for nursing home care, then said beneficiary shall cease to be a Trustee of this Trust or any Trust share hereunder and, thereafter, the Trustee shall not make any distributions to said beneficiary that might decrease or eliminate that beneficiary's eligibility for any public benefits based on need, such as,but not limited to, Medicaid or Supplemental Security Income. Article VIII In0 order to carry out the purposes of the Trust established by this Will, the Trustee, in addition to all other powers granted by this Will or by law, shall have the following powers over the Trust estate, subject to any limitations specified elsewhere in this Will: (a) to retain in the form received and/or to sell either at public or private sale, any real estate or personal property except that which I specifically bequeath herein, (b) to manage real estate, (c) to invest and reinvest in all forms of property without being confined to legal investments, and without regard to the principal of diversification, (d) to exercise any option or right arising from the ownership of investments, (e) to compromise claims without court approval and without consent of any beneficiary, (f) to file fiduciary/income tax returns and pay the tax due for any year for which such a return is required, -4- (g) to make distributions in cash or in kind, or in both, and to determine the value of any such property, (h) to the extent any mist hereunder is the beneficiary of a Retirement Account (as hereinafter defined) my Trustee shall draw the benefits from the Retirement Account in amounts sufficient to meet the minimum distribution requirements of IRC Section 401(a)(9) and the regulations thereunder(the "Required Minimum Distribution"). Notwithstanding any provision of the trust to the contrary, the Required Minimum Distribution shall be paid to or applied for the benefit of the income from such trust, or if there is more than one income beneficiary,my Trustee shall make such distribution to such income beneficiaries in the proportion in which they are beneficiaries or if no proportion is designated in equal shares to such beneficiaries. "Retirement Account"means a plan qualified under IRC Section 401, or an individual retirement arrangement under IRC Section 408, or a Roth IRA under IRC Section 408A, or a tax-sheltered annuity under IRC Section 403 or any other benefit subject to the distribution rules of the IRC Section 401(a)(9), or the corresponding provisions of any subsequent federal tax law. It is my intention that this trust qualify as a "conduit trust" under IRC Section 401(a)(9) so that the mist beneficiaries shall be considered designated beneficiaries for purposes of the minimum distribution rules, and that distributions may therefore be taken over the trust beneficiary's life expectancy (or the life expectancy of the oldest trust beneficiary). The Retirement Accounts shall not be subject to the claims of any creditor of my estate and they shall not be applied to the payment of my debts, taxes or other claims or charges against my estate unless and until all other assets available for such purposes have been exhausted, and even then only to the minimum extent that would be required under applicable law in the absence of any specific provision on this subject in this my Will, _5_ (i) to employ any attorney, investment advisor, or other agent deemed necessary by my Executor, to pay from my estate reasonable compensation for all their services, 6) to conduct along with or with others, any business in which I am engaged in or have an interest in at the time of my death, and (k) to receive reasonable compensation in accordance with their standard schedule of fees in effect while their services are performed. Article IX I hereby appoint my daughter-in-law, CHARLOTTE C. HALL, as Trustee of any Trust(s) created in this Will for the benefit of the issue of my son, R. MARSHALL HALL. In the event of the renunciation, death, or inability to act, for any reason whatsoever of CHARLOTTE C. HALL, I nominate, constitute and appoint my daughter, IMSTINE E. MINER, successor Trustee of any Trust(s) created in this Will for the benefit of the issue of my son, R.MARSHALL HALL. I hereby appoint my granddaughter's husband, JUSTIN J. HERTZ, as Trustee of any Trust(s) created in this Will for the benefit of the issue of my granddaughter, CARLY L. HERTZ. In the event of the renunciation, death,or inability to act, for any reason whatsoever of JUSTIN J. HERTZ, I nominate, constitute and appoint my son, R. MARSHALL HALL, successor Trustee of any Trust(s) created in this Will for benefit of the issue of my granddaughter, CARLY L. HERTZ. -6- Y i'd ("Cir.'J-"�rYt bstiiJ9b ' fl;o 14 .dGU+.i'1i3.: 7araPt§72J''dfC�. .4'sf% `.''Ei�*"�%G Yolgfr5 cil ff91 rf:v"iS'^fl%:1n4,Df.i III' nt":oig;1fx°,qL7CY7'J3f�tLit'..'t.Xi"'JZ'1'fi:�+'�#°�Li1 anvil, +(:a'Ct Or;brfu wrd a = �ni bj8rnca fri, I mwflw cil a At l url {ma <n-�W) &i-f "frr °,IaOL- 3ac',gfoo W (a b�;. "dt'rab��txa"tcstxLki any'ii �n,r}�tjrfi uf> 'in ,Ifvb�-fba b'»^bow,-diof; rNYr v5,,m;h a: �x t,,° f,iazrr x ri r r aldt, 4l. q 3i'f's, 4j sa e.?-Ii 3dt*Itf4'f,' i;i'sjjJ qj Ill'Al P"S.I -'a3 ei r} m fmlu Ivin O •1is:� S.,..t.#A1I «:i i a : . , ,'i{X 3i ki v u'zySt'!I'= iT. 'trr *af eaJ FE'dl Lr'tt&xir lint. "ilt v: ra�i: .2..tS,o .=� a!�,P�t ." b.�° �M•3vt�'s �f". �rzcraCw�ra yzexr.Lft ,i`,sjr's[ 27•u'r'T9CIfCe t3 m'If. J;>f?>t�tYtj 3f`b fsj ¢}tfD vi,vi rIarf.Upv-,od 11; `c"I{TEf,b%,, iI£'f,# 'urL l`,A n f1. - �!.A.: €, trot",„n��P,'�Gi;r.l,�•i�Ct«Jr`�lrcjg�..i?3�r,.:rn-al`;fa:Yt �Q�.1. -„.D.�w'Y?� f'j” '.[,,,(- �... ...x.�i��. � I, EDNA G. HALL, Testatrix, who signed the foregoing instrument, having been duly qualified according to law, acknowledge that I signed and executed this instrument as my Will, and that I signed it willingly as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by EDNA G.HALL, the Testatrix, on Tgn-� cod 2013. Notary Public EDNA G.HALL C MMaNMI:LTH OF PENT SMAMA Notarial Sea, MM-ism M.Kain,Notay.Public Susqudiannarwp.,pauphln County My Crnnmhsion 6gnrua ntm.sa.74fa�__. We, the undersigned witnesses who signed the foregoing instrument,being duly qualified according to law, depose and say that we were present and saw the Testatrix sign and execute this instrument as her Will; that she signed and executed it willingly as her free and voluntary act for the purposes therein expressed; that each of us in her sight and hearing signed the Will as witnesses, and that to the best of our knowledge, that she was at that time eighteen (18) years or more of age,of sound mind, and under no constraint or undue influence. Sworn to or affirmed and subscribed to before me by i(,/NdA T. ak5cAl and DEPnt_ stn s / witnesses,on A,)..q_° O d 2013. wit" Notary Public COt•SMON"WrAL'H OF PENNSYLVANIA Notarial Seal MWissa i4.Kein,Notary Public Susquehanna TWP.,Dauphin County My COmmisslon FxplrM AOSI,It.;024, -9- REV.183 EX(o4-10) RECORDER'S USE ONLY pennsytvania REALTY TRANSFER TAX State TeX Paid pEMMMGFa Ruf STATEMENT OF VALUE Book Number - Bureauat Individual.Tams Page Number...^. PO BOX 280603 . Hwrubu%PA17i2Ea60 See reverse for instructions. Date Recorded Complete each section and file In duplicate with Recorder of Deeds when (1)the full value/consideration is not set forth in the deed, (2)the deed Is without consideration or by gift,or(3)a tax exemption is claimed.A Statement of Value is not required If the transfer Is wholly exempt from tax based on family relationship or public utility easement.It more space is needed,attach additional sheets. A. CORRESPONDENT-Att inquiries may be directed to the following person: Name Telephone Number: Linda J.Olsen of Hazen Elder Law (717)540.4332 Mailing Address City State ZIP Code 2000 Linglestown Road, Suite 202 Harrisburg PA 17110 B. TRANSFER DATA C. Date of Acceptance of Document Grantar(s)/Lessor(s) Grantee(s)/Lessee(s) Kdsgrre E.Miner and R.Marshall Hag Co-Executm of the Estate of Edna G.Hag Kristine E.Miner Mailing Address Mailing Address 1329 Swope Drive 1329 Swope Drive City State ZIP Code oty State ZIP Code Boiling Springs PA 17007 Boiling Springs PA 17007 D. REAL ESTATE LOCATION Street Address City,Township,Borough 129 South Locust Street Borough of Shiremanstown County School District Tax Parcel Number Cumberland 37-23-0555-272 E. VALUATION DATA-WAS TRANSACTION PART OF AN ASSIGNMENT OR RELOCATION? ❑Y 0 N 1.Actual Cash Consideration 2. Other Consideration 3.Total Consideration 1.00 40.00 = 1.00 4.County Assessed Value S.Common Level Ratio Rctor b.Pair Market Value 155,000.00 x .97 = 150,350.00 F. EXEMPTION DATA Ia.Amount of Exemption Claimed 1b.Percentage of Grantor's interest in Real Estate ic.Percentage of Grantor's Interest Conveyed 150,350.00 100% 1 100% Check Appropriate Box Below for Exemption Claimed. ® Will or Intestate succession.Edna G.Hall 2013.1275 (Name of ecedent) (Estato File Number) ❑ Transfer to a trust. (Attach complete copy of trust agreement identifying all beneficiaries.) ❑ Transfer from a trust. Date of transfer into the trust If trust was amended attach a copy of original and amended ru . ❑ Transfer between principal and agent/straw party. (Attach complete copy of agency/straw party agreement.) ❑ Transfers to the commonwealth, the U.S. and Instrumentalities by gift, dedication, condemnation or in lieu of con- demnation. (If condemnation or In lieu of condemnation, attach copy of resolution.) ❑ Transfer from mortgagor to a holder of a mortgage in default. (Attach copy of mortgage and note/assignment.) ❑ Corrective or confirmatory deed. (Attach complete copy of the deed to be corrected or confirmed.) ❑ Statutory corporate consolidation, merger or division. (Attach copy of articles.) ❑ Other(Please explain exemption claimed.) Under penalties of law, I declare that I have examined this statement,Including accompanying Information, and to the best of my knowledge and belief, it Is true,correct and complete. Signature At Corresponde t or Res sibie Party Date !0 LfW56 TO COM E THIS FORM PROPERLY OR ATTACH REQUESTED DOCUMENTATION MAY RESULT IN THE RECORDER'S REFUSAL TO RECORD THE DEED. t Holdings by Investor Edna G Hall Debra Hillman Combined Account Portfolio 129 S Locust Street Mastand&Barrick,Inc. Date: 11/2512013 Shiremanstown,PA 17011 3600 Tdndle Road Created: 12/06/1013 Camp Hill,PA 17011 717-761-6606 Edna G Hall Acet Name:EDNA G.HALL 129 LOCUST STREET SHIREMANSTOWN PA 17011-6733 Acct No:5W8155983 Acct Type:Individual Rep.No:HTF rAseat Name Ticker Asset Type Mgt.Name_ Quantity _Price($) _ Value($)I AMERICAN CENTURY INTL GR INV TWIEX NON-US STOCKS CENTURY 298.25 13.67 4,077;02 INVESTMENTS AMERICAN CENTURY VALUE INV TWVLX US STOCKS AMERICAN 8.10 13,750.15 INVESTMENTS BROKERAGE MONEY MARKET CASH MONEY BROKERAGE 1,136.76 1.00 1,136.76 MARKET ERSHEY CO DOM HSY US STOCKS 1,011.00 95.99 97,045.89 OAKMARK FUND#110 OAKMX US STOCKS FOUNDS AKMARK 238.33 64.36 15,338.85 Account Total: $131,340.67 InvestorTotal: $131,348.67 E ( > C- z \ < = ) - _ )] \ I\ § \ 00 ! \ ( VS. DO ( i ( k ( - ® % - w ) ■ � _ _� C _ - 2§ k§ § ( � g [ ) �E ® § E $ � � \ � s l � � � - E 3� RL W9 / A ) ( � o § - § 7 9 7E7 % E # E j 2 � CL [ K." 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A o N n ° - 3 c '°_ >• n ° o n s o J a o o N c. >• ° J S d ° b (D nG+ N d a IS m tO o ddj fn'I 6 fd'1 F O 3 t0 3 p z 3 F 0 m C N y 1p y^ g n 'F A f 3 m J. o n w m d �_. y _ E O� `D pn-S. ° O n d b d_ N (D 2 O p -J d p �. V 3 n m n N 3 d � � p b d_O c m 3 >• m N ^ n C o = 3 3 � N d 'c to =co m as o SN s n R o c a c °^ o N Frc d N J ^ d T O j O d N % N n ^ C "o f3'1 f O 3 d fD N d^ =1 Q N d =1 -'I < a4� J 9 C O 6 tDI N C j d C L ^ �. O rgF. omo n d mo A m � N3J d Fr o o n afi yE _z POSTMARK C R E D I T U N I O N Member Statement Page 1 of 1 2630 Linglestown Road, Harrisburg, PA 17110-3666 Account Number 4171 RETURN SERVICE REQUESTED Social Security Number Confidential (717) 671-5119 • 1-888-671-7678 Statement Period 07/01/13-09/30/13 Our Auditors, Carver and Associates,LLC, CPA's 00027 are conducting a verification of all member accounts. I�I�IIII" 'I'II"II"'I�IIII�II�I��I'll'I�'lll"I��I'�'I�IIII�II If your account balances are not correct,please EDNA G HALL contact the auditors in writing at: 1221 Wyoming 129 S LOCUST ST SHIREMANSTOWN PA 17011-6733 Ave—Forty Fort, PA 18704. Thank You. s ,mil/ Summary - All Accounts Beginning Ending Type Balance Balance SUFFIX:00 REGULAR SHARE ACCT $8,592.63 $8,593.70 SUFFIX:00 REGULAR SHARE ACCT Trans Date Description Withdrawal Deposit Balance 07/01/13 Beginning Balance 8,592.63 07/31/13 DIVIDEND 0.36 8,592.99 08/31/13 DIVIDEND 0.36 8,593.35 09/30/13 DIVIDEND 0.35 8,593.70 09/30/13 Ending Balance 8,593.70 Y-T-D DIVIDENDS: 2.74 ANNUAL PERCENTAGE YIELD 0.05007. ANNUAL PERCENTAGE YIELD EARNED 0.0494%, Summary For 2013 Total YTD Totol YTD Reporting SS# YTD Dividends IRA Dividends Other Dividends Withholding Forfeitures ## ##-6593 2.74 .00 2.74 .00 .00#- ACCObN �-' J J CUSTOMER NAME(PRINT)(.' Y t_ j-DESCRIPTION: g PARTIAL WITHDRAWAL CLOSING WTHDRAWAL CUSTOMER ID`\ � Original-P�irg Work ;1'�t/l1.(:✓1f �',!<'�1'�!/> G� �� Copy-Branch CUSTOMER SIGNATURE: i SEQ.NO. } 2 1 9 0 7 8 7 J ti �i { ? JC s i $ ` 'l c� j�` • iC i ® Mff Bank Lbdmunding what� Trindle Road Office If you have any questions, please call our Telephone Banking Center at 1-800-724-2440 12/05/2013te Business 12/06/2013 Date Time: 02:34 PM Checking Deposit $19,839.50 ****0331 4350/11 6 M Thanks for visiting us today. We are happy to assist you! Masland & Barrick Advisory, Inc. 3600 TRINDLE ROAD Camp Hill,PA 17011 dh i I Iman©maslandandbarrick.com Phone: (717)761-6606 1 Fax: (717)761-7524 February 19, 2014 Edna G Hall c/o Kristine Miner 1329 Swope Drive Boiling Springs, PA 17007 Dear Kristine Miner: Enclosed is your 2013 Form 1040, U.S. Individual Income Tax Return, prepared from the information provided. The original should be signed, dated, and mailed on or before April 15, 2014, to the following address: Department of the Treasury Internal Revenue Service Kansas Cit3M0° 999 015 Your federal return reflects a refund of$792. Yo euld-mceiue•a•check,fGi tlii amount ount in approximately four to eight weeks. Enclosed is your 2013 Pennsylvania income tax return,prepared fron original should be signed, dated, and mailed on or before April 15, 2( Pennsylvania Dept. of Revenue iJ No Payment/No Refund 2 Revenue Place Bank Harrisburg, PA 17129-0002 Uxb=swiding what§importane Your Pennsylvania income tax return reflects neither a refund nor: Spring Garden Office If you have any questions, please Thank you for the opportunity to be of service. For further assistan cal 1 our Telephone Banking Center hesitate to contact this office at (717)761-6606. at 1-800-724-2440 Today's Date: Business Date: Sincerely, 06/12/2014 06/12/2014 Debra 0 Hillman CPA Time: 10:56 AM Checkilg Deposit 7,7 ****0331 ` ! 4344/14 61 a r5,r3i�';�y!c(�' IRt�l!ot°Fi1N>.E�r��yF'sM �af1'�Kdl.� I ) N II 4 y M y.1` ' . .. . .•. /IY a17,�d�yh{rjr°-S�• 9l, ODYV I�D,L(SUh�rs.J �� 33+5 ' xynf`r - p '4113 D Sd%71`i7' - -xt7�55 ,S. iil P 1YQ D p10�Yrg�'f }'¢Cr RC1't'x� , wa�5 < r1.t-d7: h rek 431CrtC•: v f x_ f1p'C ji•f `I I J� b Gt h llfi�cl� 1•!!} ILV }'--6jj }I'✓,3 �L RC: . x131i��` n.xlr��rJ1 1riy a '11'."K1f _ �f �uk � "'Imp liiJrf E r3vaiy"�L.f3? hIRP - ks!1 it uS ��cn.mnl.i m•- m- ••,ry i/ a s; y J c fi+.Klm ra O Dy 4'lln+f v' �) Cie3 ";j ty - i cn- m94. EP ca,✓g,t f:�! s A 9 1 at O Y �A A rays f'n Iry ¢yt If H l - ltD�t S . �T41 �JM .1. xyo F''tp SeV 7f+t,Y f[Y"' q•egS, �v rAaL f _ A'y 5iL 5 as4b of 4+1C t3A§< iZ ru �1z�, ae.:F IC.�;,r.��r,� i iz� �1J..s::- �'Zi.•Y'.. Y 0/�3� • W fli , .Iy VYI•l4`9S <J'Il, FIII N z HIND ' 1i L�K 1 ryl ? - SYe M.r4j� r x' rL ry 06P Ll w L�1tP is -ti-F�I iu .t aU!''.i• r 7r sE+ x�`>lka' .•.,A a JT a "'K j'1 Yr Tilk It x � N` 1 mi "k, It Rl• -1 vl rr p �t > '3 IN tf w+"i 11 ^ ' jJ„ 11J :.i�' � y. se Or>•kr�d� t,� '�+r �;� �Ifi Cr 1l7r3 �nW t J im r?p3 F1t nSfiRj� S 3' .1 Siih �N on cjxk >!';IS }lY�,r}` id aK jN�•�'. .S t JGnVV Ib t \ t y,�21 -x�Ct3s'4 . - . . .. .. 'I f,<�p�t3�ry �1�fA,.>•tyc i4��Ji' fa h'�x.,.l$� s'�. . I "jaqS.Y){r, k 1A1'f .i l t i t'"va'Y Q-��1• i p D n¢ryfp-.r.F"'t Y`•y�f 9� { 31x>3. N/a�Y�ly�tl � i r 1�4iGgdF�J�tN ATV� i rx� , >F}`-.lx'iy.a,�y f+'r x ��NS 13'�5yr a�� At,•- r c,. I: S..a•11 j t�Cq' IidS1, �y�nuts w•�bt'f}��pf1 g'xrJ"� ! 'r4 ���,-,1,`M �!P,.�1'°.Gs�l ]m!}Y�f�.l..r"�^d.�-' �P` ^•z 33 ' .. 8 .R..:..uta.u:,...� •.N 4.zw.Y rrn�,cl.a_:. I r Lf!?�„ BRICKERS AUCTION Buy & Sell on Commission - Complete Sale Service .: 93 Texaco Rd., .Mechanicsburg, PA 17855 766-5785 Personal Property of d Address 'Sold At Public Sale Ra 20 !Lk Outstanding 'rotas Sale Total-Cbecks �i�-C"�(N1_•�...rv_ ' 643 �T�•-�' •.. A Total Cash �,....� Cash After Payout Expenses Auctioneer & Clerks Adv. Cost L f b D 0 Sale Setup or Help OD Total Eximnses ja 7 l'A1UL -- ,3f31�1� vJjrce DOS 4/ Euolq PA 17025 DATE INVOICE# (717) 732-5552 FAX(717) 728-9501 Federal Tea Number 23-2464545 t 1252013 13-2613 fHal,Edna LL TO PATIENT NAME: Edna Hall ADDRESS: 129 S Locust Street S Locust Street emanstown,PA 17011 ADDRESS: Shiremanstown,PA 17011 PICK UP: Residence TAKEN TO: Holy Spirit DESCRIPTION: Stretcher TRIP NUMBER 13-00686 DATE OF SERV... DESCRIPTION UNIT RATE AMOUNT 1 1222013 Stretcher Transport-Round Trip (Non-Member)- 160.00 160.00 A0130 I 1222013 Stretcher Van Mileage-Non-Member Rate 20 3.00 60.00 For your convenience,we now accept Mastercard,Visa and Discover. Card Type: Name on card: Credit Card Number Expiration:__/_ Amount to be charged:$ I agree to pay the above total amount according to card issuer agreement. TOTAL DUE Signature: Comments: Your payment is due upon receipt Medicare and most insurances do not cover this service. If you need to check with your insurance company,please ask if your plan covers transportation code A0130. $220.00 Please Note: Unpaid accounts may be sent to a collection agency after 90 days. 5024 Simpson Ferry Road Mechanicsburg, PA 17050 (717) 697-4033 i 1 2,-7 Window Completion Certificate ,< Customer Info: r - Edna Hall Job Number. v' 'i 129 South Locust St Contract Date: 11/5/2013 Shiremanstown, PA 17011 Salesperson: Jason Korns I ( 1 (717) 737-5903 Completion Date: Our philosophy at West Shore Window&Door is to provide the best quality home improvment i products that are professionally installed to assure complete customer satisfaction. Please take a a . moment to review tl . - — -- -- r DAVID N.MINER 3236 kRISTINE E.MINER 50.18WI3 1329 SWOPE DRIVE PH.717-258-1749 I t a-r 13 BOILING SPRINGS,PA 17007 oire ORDER OFE G 25 (JV DOLLARS BANK s s The company repro workmansh ip of bc 1:0313018461: 513301879n° 3236 r.' maintenance requiim� remaining debris. I hereby certify my complete satisfaction with the performance of the company crew and the installation of my new windows. ;? s , - I Customer Signature: 2. /' Date: y; Comments: 8AL N 1 t Company Signature: Date: s: ......,s wrr. omn w Oytu Your Electric Usage Profile Billing Summary \�, (Billing details on bac[ ETNA G HALL Balance as of Nov 2Z.2013 ,�:- $0.00 Charges: 129 S LOCUST ST _Total PPL Electric Utilities Charges $30.92 Meter: Meter:94186684 ANS7084 PA 17011 Total ResCom Energy Charges $56.92 Your next meter reading is on or about Dec 23, 2013. Total Charges $87.84 This section helps you understand your year-to-year Automatic Bill Payment on Dec 13,2013 $87 8 electric use by month. Meter readings are actual unless Account Balance $87,8, otherwise noted. M 2012 02013 PPL Electric Utilities'price to compare for your rate is$0.08777 per kWh. This changes the 1st of Mar,Jun,Sept,and Dec.Visit papowerswitch.com s4 c 45 or www.oca.state_pa.us for supplier offers. x 36 Your Message Center T - - o 27 • Go Paperless,and receive a FREE LED at a 18 pplelectric.com/gopaperiess • Information about appliance energy use and tips on Ir 9 saving energy are available through the Energy Library o on our Web site, pplelectriccom/e-power J F M A M > > A s 0 n D • Before digging around your home or property,you Months should always call the state's One Call notification system to locate any underground utility lines. You can monthly Days Average Average do this by simply dialing 811,which will connect you to the One Call system. Be safe and call 811 before you kWh Comparison '. dig. Nov 2013 29 537 19 46F Nov 2012 29 385 13 46F Billing Period Type Reading Payment Methods Nov 21 Actual 61831 ✓F� Online at: ®By phone:1-800-342-5775 Oct 23 Actual 61294 V pPlelectric.com or call BillMatrix(service fee applies) at 1-800-672-2413 to pay using Visa, 29 Days kWh Billed 537 MasterCard, Discover or debit card. _ ® By Mail: Correspondence should be sent to: Dec 2012-Nov 2013 6452 1 538 2 North 9th Street Customer Services CPC-GENN1 827 Hausman Road Dec 2011-Nov 2012 6563 j 547 Allentown, PA 18101-1175 Allentown, PA 18104-9392 Other important information on the back of this bill 4 PPS Aect. No. Due Date Amount 36770-73007 Auto Pay AV 01 000614 41105 8 2 A- 5DGT 111111,II1f 11..11"111'II'II'I'1111.1,11.1.111.111"I'IIIIIIII'1' G HALL 129 3 PPL ELECTRIC UTILITIES SHIRF_MANSTOWN, PA 17011-6733 LOCUST ST 2 NORTH 9TH STREET CPC-GENN1 HI ALLENTOWN. PA 18101-1175 "141111111ni1'uflld'I'lid^Ih11u111114°^lu°Ib°fill 1 3600000878460000087846 3677073007 Atxount Information h fslredu�seotri/myvGrfton*u?µ SfaMnelt Deh: 17!18/17 1Rrih a:On; Yf�xg. o :� �d&fcp x ': EDNA 6 HALL giV11C. 41Ir41N9iYi .'.*�`';.(�k»'�. Y7ewmtdr�?y;. _Y1B1✓!� _. ,�iE. Ykx 'i.!'.N `>r'•^t �Qf¢enfndpY;"gG6ilppeiFr'ea%'-.�'a''� 'I;f`M Account Summary :Ftts:2rn'StiU Kbc:Y.%(.-'s'L1L.�A:'yt u:.Y"J.YS Previous Balarxe _ _. ._. - ._-_ $156.89 . Payment Neceed Nov N 4 -$15&89 {i ll' I(' • Balance Forward ..._ . S.00 Gat The speed You Need Faster Internet Isn't always luxury,it's a necessity, Near Charges For just Mime.more you can upgrade to Fi08 Current Activity Ouanlum 5025 Mbps!nternet.To order,visit _ . -_ry $144.96 vedzoncom/1 9e flat —°--- ---- iosglantum50 end 1 America's Taxes,Gwemmemal Surcharges and Fees $4,72 top-rated Internet today.Limbed-Ume alter.Speeds . __..... .__ . .. ._.. not avail.in all areas.Taxes apply. Verizan Surcharges and Other Charges 8 Credits 59.21 Keep Up With Internet Speed Total New Charges Due by December 10,2013 $1 FTOS Quantum Internet lets you blaze through all the Total Amount Due things you do mline.Stream movles,download music, 1 758.89 . or upload photos and videos lightning fast.And,it you ✓ �' ' are into gaming,them's virtually no lag time.Call 1-800-593-4802 and ash about FOS Quantum bundle deals! Get More,Save More Cali 1-888-598-0875 to ensure you're getting the best Verizan services at a great vafue-from Phone, Internet and TV to morey saving hundfes,international Plana and tun add-om Together we'll find ways to save you even mom. Want Automatic Payment? QUBatIOns about your bill or service? Emoll below or at Vedzon.com to authorize ur tirmnclai Yew your bills in detail at vedzon.com or call 1-800-VEFUZON(1-800-837-4966). Ira When asked for your eccourd number,please enter 8978007332.Customers wlth Institution to deduct the amount of your montbly bill tram disabOities call 1-800-974-6006 TTY. the account associated with your enclosed check and send payment Arectly to Verizan To discontinue Automatic Payment,call Verizon Please keep a copy of this authorization Please return remit sli with P Payment. Fo enroll in Automatic Fayment(Sign and date be" Account Number. 79 9000 6978007332 02 ® Amount Due: $158.69 111613 By slprilamon I verityllal I heveralemd one Make check payable to Verhen etapa0 erorams MmoanVOUloluymroeoce o AN llabo ac bill payml s n1111. ❑❑ 00061615 01 AV 0.360 VY1116110300)X ®NA G HALL 129 S LOCUST T SHNMNSTWNPA 17011-6733 1'1111'I1111116111d11111"'lll'IIIIII13 I(IIIII'lulndul is 11 'lllll'411111111iI 111111141"Il"1111111'lllllJill 1151111111111 PO BOX DALLAS Tx 75392-0001 79 9000 8978007332 02N00000000000 00000015889 02 II Baum uaiance on your last bill was.___.___, $59.73 - e _ «+ +r•.rrr Thank you for your payment of_�___....________. 59.73 custo!W Number,- • EDNA Summary for Service to: Your balance as of 11/27/2013____.___�_ -- g r c.:... ;_:..I EDNA G HALL -------�6 218719239517 129 S LOCUST 5T Current Bill Informatinn.(im!Iaillty Supplier Commodity( 115 CCF at$0.69461 _.. i9.88 Distribution Charges(First 50 CCF at$0.336)00) _. 16.60 Rate Classification: Distribution Charges(Next 65 CCF at$0.27138)._ 17.64 Residential Heating-CC P0.State Tax Surcharge,.,_...,.,,,,,,_ Tot:: . ________._.._.._._ -0.20 �..ru:budtac>-yVi lluiii 10/Remote3 Device 17/22/2013(28 days) UGI UUltty charges owed this 6,11 �_�..__ ��__ 12417 Remote Oavice Read 124.17 Questions? Current gill Information-UGI EnergyUnk Call OX 800-276-2722 or write to UGI at UGI EnergyLink gas costs are shov n in the Re BOX,PA 1 supplier charges above. Reading,PA 19612-3009 �•��. ___- - Yourcurrent UGI charges include Total Amount pug by(12/18/2013).___..__.._._..___.._. State taxes totaling about$1.36. '-'""-"-' ' --- S 124.1 f,_. e i Mwlar lern.n. ____ __ 7.60 •u_._b-__. ... ....y t ........ .. .... 3 /.a 1356662 2667 remote J 6.24 � (remote) 29112(remote) 115 5.46 I General Information 7.58 °OC.L:,c:Sy;a;,;,p,6a(u.u.a.Uoi EnergyLink) 3.90 1 MERIDIAN BOULEVARD 3.12 SUITE 2COi 2.34 WYOMISSING PA 19610 or Phone 610-373.7999 1.56 •Cammodily prices and charges are set by the nalu ga;;DVV+�tr �+a:a;J,oson. The 0.78 Public Utility Commission regulates distribution prices and services. 0.00 Important Messages from UGI - N O J F M A M J J A S O N •Your currant price to compare is$0.66919/CCF. 2012 Months 2013 'Your total annual usage is 953 CCF. Your average monthly usage is 79 CCF. °We can make your energy costs easier on your budget with our 12 month Budget Billing Last This plan. Your monthly payment would be approximately$93.00. For more information Average Year Year about this plan call UGI. _ CCF/day 3.50 n.-++ Gaily temperature q2-F4pF Keep this part for your records. Important information is on the back of this bill. Tri County Animal Hospital Fax: 717432-2540 417 Range End Road Dillsburg, PA 17019 717.432-2453 Invoice Reference Number: 0036048 Date: November 27, 2013 Kristine Miner Patient Number: 01942-0004 1329 Swope Drive Patient: Lily Born: November 26, 2011 Boiling Springs, PA 17007 Species: Feline Sex: Female-Spayed Breed: Domestic Short Hair Color: Tiger Rabies Given: Weight: 9.00 MicroChip ID: None Follow Up Action I Due Date No followup actions scheduled at this time. Date Product/Service Quantity Tax Discount Amount Vet 11/26/2013 S601 -DECLAW-FRONT FEET 1.00 0.00 175.00 ST 11/26/2013 P058 - POST OP INJ. CAT 1.00 0.00 17.00 ST 11/26/2013 A003-ANESTHESIA-INJECTABLE 1.00 0.00 10.00 35.00 ST 11/26/2013 Z072-E COLLAR 210 1.00 0.48 8.00 ST 11/26/2013 M010-AMOX SUS 250MG/5ML 100ML 1.00 0.00 12.00 ST Sub Total 0.48 10.00 247A0 Less Discount 10.00 Plus Tax 0.48 Amount Due this Invoice 237.48 Account Summary Beginning Account Balance-1112712013 0100 Payment-Check 3239 -237.48 Invoice 0036048-Lily 237.48 Ending Account Balance-11/2712013 0.00 Transaction Processed by: ST Printed: 11/2712013 03:10 PM Created: 11/26/2013 03:03 PM Page: 1 DO NOT SEND PAYMENTS TO THIS ADDRESS Pveniserw MASTERCARD ORRoLUOV R,RE Rao - Dept. 19687 ❑uAarerrcwRO - ❑DISLUVER ' ❑wse s P O Box 1259 IIIIIIIIIIIIIIIIIIIIIIIIIIIII�IIIIIIIIIII Oaks, PA 19456 MINT CMUHOLOER NAME SLLYIRIiY f-v D-A ,IVIII VIIII�IIIIII IIII eM:x Uf eAnn For billing questions Call: (717)932-5955 STATEMENT DATE - PqY THIS AMOUNT ACCOUNT NO.. or: (877)932-5955 12/9/2013 $13.18 ? 81354 Fax: (717)932-4856 - Office Hours: 8:00 AM -4:30 PM MIA ICES AND CnEDITS MADEAFrER STATEMENT SHOW AMOUNT To pay your bill online and register for eStatements, ATE WILL APPEAR ON NEXT STATEMENT. PAID HERE t fVl please visit us at: www.gita.com MAKE CHECKS PAYABLE/REMIT TO:Iiiort Ilu,unI111IIIIP IPPdb 1°II IIIhIliul9plllpulllllll 1%70.70 EDNA G HALL Quantum g and Therapeutic Associates ' P O Box 62161 2165 ` 129 S LOCUST ST Baltimore,MD 212614-2165 SHIREMANSTOWN PA 17011-6733 IIII]IIIIIIIdll d11811 bill II III I III IIIrrr1Jr pill II III Illrrrl Please check box if above address is incorrect or Insurance PLEASE DETACH AND RETURN TOP PORTION WITH mfonnation has changed,old indicate change(s)on reverse Side. YOUR PAYMENT IN ENCLOSED ENVELOPE Patient: EDNA G HALL Account: 81354- Ser ices Rendered At: HOLY SPIRIT HOSPITAL Date Proc Payments Code Description Charge * Ad'ustments Balance 10/18/2013 99144 CONS SED>5 YRS OLD1ST 30 MINUTES 296.00 8.20 11/20/2013 PMT MEDICARE PART B-NOVITAS 32.16 11/20/2013 i CR Adjustment MEDICARE PART B-NOVITA 255.64 10/18/2013 99145 CONS SED EA ADDTL 15 MINUTES 296.00 4.98 11/20/2013 f PMT MEDICARE PART B-NOVITAS 19.50 11/20/2013 I CR Adjustment MEDICARE PART B-NOVITA 271,52 11/6/2013 47556 SCOPY DIL.BIL.DUCT STRICT.STEN 1551.00* g2,g1 12/5/2013 I PMT MEDICARE PART B-NOVITAS 324.60 12/5/2013 CR Adjustment MEDICARE PART B-NOVITA 1143.59 11/6/2013 47525 CHANGE PERC. BIL. DRAIN. CATH. 967.00• 8,29 12/5/2013 PMT MEDICARE PART B-NOVITAS 32.51 12/5/2013 CR Adjustment MEDICARE PART B-NOVITA 926.20 11/6/2013 74363 PERCMILATATION BIL.STRICT S&I 235.00 8.46 12/5/2013 PMT MEDICARE PART B-NOVITAS 33.18 12/5/2013 CR Adjustment MEDICARE PART B-NOVITA 193.36 11/6/2013 75984 CHANGE PERC.DRAIN.CATH.S&I 175.00* 6.76 12/5/2013 PMT MEDICARE PART B-NOVITAS 26.49 12/512013 CR Adjustment MEDICARE PART B-NOVITAS 141.75 11/6/2013 99144 CONS SED>5 YRS OLDIST 30 MINUTES 296.00* 296.00 11/6/2013 99145 CONS SED EA ADDTL 15 MINUTES 296.00* 296.00 11/22/2013 47525 CHANGE PERC. BIL. DRAIN. CATH. 967.00* 967.00 11/2212013 47505 INJECT IN EXIST CATH CHOLANGIO 425.00* 425.00 11/22/2013 75984 CHANGE PERC.DRAIN.CATH. S&I 175.00* 175.00 11/22/2013 74305 CHOLANGIOGRAM POST OPERATIVE 86.00* 86.00 I Current 31 -60 ' 61 -90 91 -120 Over 120 BALANCE DUE _ $13.18 13.18 0.00 0.00 0.00 0.DO PAY BY Due Upon Receipt THIS ACCOUNT BALANCE IS YOUR RESPONSIBILITY. For billing questions call: (717)932-5955 PLEASE REMIT PAYMENT IN FULL OR CALL OUR or: (877)932-5955 OFFICE IF PAYMENT ARRANGEMENTS AND/OR Fax: (717)932-4856 INSURANCE INFQRMATIOfNl IS NECESSARY. Office Hours: 8:00 AM - 4:30 PM Those charges shown with'an "*"indicate pending insurance. To pay your bill online and register for eStatemen IIIIIIIIIIIIIIIIIII�IIIIIIIII�IIIIIIIIIIIIIIIII�„IIIIIIIII R IMPOR EN please visit us at: www.gita.com III II SEE REVERSE SIDE FOR IMPORTAN BILLING INFORMATION 19870-70 r tL 11 (iill �.l L cLr�tti t G Date I No., Reg. No. Clerk FORWARD 1 4 6 3 3 5 6 7 r 8 9 11 12 J _ re I ' l ( 13 14 15 rem Aoo � y,wa m Dery — x e„e, i. roved uewm m ona. L9 Y, 3�' F4.pnn 1n U.M Am Mm POBo 40047 ' Ro ke VA24022-0047 II II ro Ir urLr ull r 1 1 dl n r 1 I d dl Jr Information as of December 23,2013 Policyholder Page 1 of 2 EDNA HALL Edna Hall C/O-KRISTINE MINER C/O Kristine Miner 1329 SWOPE DR Poli number BOILING SPRGS PA 17007-9612 197584626 Your policy provided by Encompass Ins.Co,of America Your Encompass agency is Wells Fargo Insurance (866)882-9520 Minimum premium amount due 107.16 Polity period — Effective February 13,2013 through Installment fee 5.00 February 13,2014 12:01 a.m.standard time To pay in full amount due by January 13,2014 $112,16me �segments for which piemwm is ue --- ��9 S LOCUST ST Ways to pay SHIREMANSTOWN,PA17011 Automatic payment plans Your payments can be automatically See your Policy Coverage Summary for 0 deducted from your bank account You can choose to pay monthly or complete schedule of your policy coverage. all at once.Visit our online Customer Care Center at encompassinsurance.com or contact your independent agent to apply. Online banking Be sure to enter 1975846260213 as the account number and P.O.Box 4310 Carol Stream,IL 60197-4310 as the payment address. Automated plane service(14866-430-2916)or www.encompasslnsurmwe.com Pay using your credit or branded debit card.See the"What you should know"section in this bill for additional payment information. Additional options You can also pay your Will by mail or at your Independent Agent's office. Detach bottom portion here * P E N N S Y L V A N l p 00010242100357942070000000000006039012 AMERICAN WATER PO Box 371412,Pittsburgh,Pa.15250-7412 Account Number 1024-210035794207 For Service To:129 S LOCUST ST Due Date December 31, 2013 Total Due $60.39 Check this box for address changes and note new address on back. Due ' • $61.07 after 12/31/13 II1+.11111•.1if1.111IIIIIi.i.,i'I.1.11.11111'llll't..Illll'llll Arno at Enclosed $ Paid electronically.Thank you. 015384 1 AV 0.357 15385M 15384/015453 56 01 ACRM9003 ,1111•ILL11..Il.il.L.liill.11.1111111.1'III111IIII1111111111.1 EDNA HALL 129 SOUTH LOCUST ST PENNSYLVANIA AMERICAN WATER SHIREMANSTOWN, PA 17011-6733 PO BOX 371412 PITTSBURGH, PA. 15250-7412 I�Iline-a[ return �Arlk?nIwiMY-oyn-1nt 111111�1�1��1�1�1��Ulllll l�lfD�1611 along the tlottetl Ilne antl return[ s-portion wlih your payment___ BILLING PERIOD AND METER READINGS BILLING SUMMA Y Billing date: December 9. 2013 For Service To: 11 9 S LOCUST ST Due Date:December 31,2013 For Account 102 210035794207 • Billing period:Nov 07 to Dec 05(29 Days) Prior Balance • Next reading On Or about:Jan 07. 2014 Balance from last bill 34.51 • Customer Type: Residential Payments as of c2.Thank—a -34.51 • Meter Reading Measurement: Balance Forward 1 unit=100 gallons of water 0.00 Billing Measurement: 100 gallons(CGL) Current water Servic Water Service Ch rge 13.75 Meter m N045388557 Water Usage Charge($0.91010000 x 32.00) 29.12 Size of meter 5/8• Total Water Sery ice Related Charges 42.87 Current Read 3,128(Actual) Other Charges Previous Read 3,096(Actual) • State Tax Adjust ant Surcharge -0.06 Total water used this 32 units • Distribution Syste Improvement Charge(42.87 x 6.01%) 2.58 billing period • (3,200 gallons) Total Other Char es 2.52 Total Water Use Comparison(in-100 gallons) Protection Program Ions • Current billing period 2013: 32.00 CGL Customer Protect on water line 5.50 Same billing period 2012: 16.00 CGL Customer Protect on Sewer Line 9,50 • Total Protection rogram Plans 15 00 Billed Use Graph(100 gallons) TOTAL CURRENT CHARGES 60.39 35 28 TOTAL AMO NT DUE y $.60:39_77 21 14 poL ) a—Q$°1 3 7 0 U 2 D J F M A M J J A S O N D 2 0 e a c a p a u u u a c o c o 2 c n b r r y n i g p t v c 3 Important messages from Penns Ivania American Water • Effective October 1, 2013. the Distribution System Improvement Charg (DSIC) Increased from 4.20%to 6.01%. This charge funds the replacement of water distribution facilities. • Approximately 4.57 percent,or$2.76,of state taxes are included in you current bill. • Any portion of the water charges which is not paid as of 12/31/2013 will be subject to a 1.50%penalty. Questions about this bill?Call our 24-Hour Customer Service Cen r:1-800-565-7292 www.pennsylvaniaamwater.com 0153851015453ACR099ETM10002 34 (ACRD99 0153a5o101CM) 656250232211 r e NOV a T C v A N I A 00010242100357942070000000000003451012 AMERICAN WATER 1024-210035794207 PO Box 371412,Pittsburgh,Pa.15250.7412 Due r - December 3,2013 For Service To:129 S LOCUST ST Total Due $34.51 © Check this box for address changes and if Paid After Due r a note new address on back. It'I""�t�lllt�tl'i'i�lll'1'11�I'ttl� 11��"IIIIl,�I��ItI Amount E losed $ Paid electronically.Thank you. 0193111AV 0.357 te312ro193rom94zo 69 o+A XVN 004 EDNA HALL / PENNSYLVANIA AMERICAN WATER 129 SOUTH LOCUST ST PO BOX 371412 SHIREMANSTOWN, PA 17011-6733 PITTSBURGH, PA. 15250.7412 _,�.__-,_,__,l,�-„_„_,_ Please tearaiong the doitetl Tine and return tM1is portion wfth your payment.0 -_��_ BILLING PERIOD AND METER READINGS BILLING SUMMARY Billing date:November 11,2013 For Service To: 129 S LOCUST ST • Due Date:December 3,2013 For Account 1024.210035794207 • Billing period:Oct 09 to Nov 06(29 Days) Prior Balance • Next reading on or about:Dec 05,2013 • Balance from last bill 47.86 • Customer Type:Residential • Payments as of Oct3O.Thank youl -47.86 • Meter Reading Measurement: Balance Forward 0.00 1 unit=100 gallons of water Current Water Service • Billing Measurement:100 gallons(CGL) . water Service Charge 13.75 Motor No. i N045388557 • Water Usage Charge($0.91010000 x 15.00) 13.65 Size of meter _5/8” • Total Water Service Related Charges 27.40 Current Read 3,096(Actual) Other Charges Previous Read 3,081(Actual) State Tax Adjustment Surcharge -0.04 Total water used this 15 units Distribution System improvement Charge(27,40 x 6.01%) 1.65 billing period (1.500 gallons} Total Other Charges L61 Total Water Use Comparison(in 100 gallons) Protection r Plans Customeer r Proto dtion Water Line 5.50 • Current billing period 2013: 15.00 CGL . Total Protection Program Plans S.50 • Same billing period 2012: 14.00 CGL TOTAL CURRENT CHARGES 34.51 Billed Use Graph(100 gallons) 35 - - TOTAL AMOUNT DUE y $34.51 2s — Pay your bill online:www.water.paymybill.com 21 (3) Pay by phone:24-hours a day,every day at 1-866-271.5522 14 t Pay In person:Residential customers may obtain a listing of 7 payment locations by visiting www.amwater.com/myh2o 3A Pay by mail:Remit your payment to the address shown above 2 N D 1 F M A M 1 1 A S 0 N 2 O a a a e a p a u u u e c 0 0 1 v c n c r r y n i g p t v a Important messages from Pennsylvania American Water • Effective October 1, 2013,the Distribution System Improvement Charge (DSIC) increased from 4.20%to 6.01%.This charge funds the replacement of water distribution facilities, • Approximately 4.57 percent,or$1.58,of state taxes are included in your current bill. • Any portion of the water charges which Is not paid as of 12/03/2013 will be subject t0 a 1.50%penalty. • We've improved the look of our bill to make it easier to understand and find the information you care about most.To learn more,see this month's bill insert or visit our website. NOTE:Your account number has changed too. If you pay your bill electronically through your bank's electronic payment program,be sure to update your account number. This would not apply if you are enrolled in American Water automatic electronic funds transfer(EFT)payment program. Questions about this bill?Call our 24-Hour Customer Service Center:1-800-SGS-7292 www.pennsylvaniaamwater.com 660000192708 0193121019420ACOXVNETMid003 23 (ACOXVN 0103120101600) 41mmerman's Landscaping P.O Box 73 Etters, PA 17319 xmice Number 111316 Client name: Edna Hall 129 S Locust Street - Shiremanstown, PA 17011 Services Performed: - Mowed and Leaf pickup 11-5-13 ($30) - Mowed and Leaf pickup 11-12-13 ($30) - Mowed and Leaf pickup 11-19-13 ($30) - Mowed and Leaf pickup 11-26-13 ($30) - Snow cleanup 12-8-13 ($35) - Snow cleanup 12-15-13 ($35) - Snow cleanup 12-17-13 ($35) Total for Services perform $225 i UU I WQPO�TMARK pp C R E-6 I–T—U–Nj ON V-1-SA EDNA G HALL Account Number: 6640 Statement Closing Date: December 08, 2013 Xq c Sumin gry, Previous Balance $0.00 BIN Balance Payments 0.00 i 906 85 Other Credits I 0.00 otal Minimum Payment Due $25.00 Other Debits + 0.00 Purchases fayment Due Date 01/01114 + 106.85 'r Cash Advances + 0.00 Late Payment Warning: IF WE DO NOT RECEIVE YOUR Fees Charged + 0.00 MINIMUM PAYMENT BY THE DATE LISTED ABOVE,YOU MAY Interest Charged + 0.00 AVE TO PAY A LATE FEE UP TO$20. NEW BALANCE.! $106.86- Credit Limit I $6,250.00 monum Payment Warning:If you make only the minimum payment, Available Credit 0.00 ach period.you VIII pay more In Interest and it Wit take you longer to Available Cash 0 y off your balance.For example: .00 Amount Disputedi T, 0.00 it Statement Closing Date 12/08113 .. .... Days in Billing Cycle 1,, using th7s Card 32 �j a] yc Only the minimum 5 months) $107.00 payment "I C t t i f ti formation about credit counseling services, all(877)277-4932. % CustomerlSemice:(800)433-0505 191 Report Lost or Stolen Card:(717)671-5119 After Hours:(800)991-4961 I A,�h, Please send Billing Inquiries and Correspondence to: NIP CUSTOMER SERVICE PO BOX 30495 TAMPA,FL 33630 Please Mail Your Payments to: $ POSTMARK CREDIT UNION PO BOX 4519 CAROL STREAM[L 60197-4519 i NOTICE:CONTO LIED ON PAGE 3 Pago of 2 PLEASE DETACH COUPON AND RETURN PAYMENT USING THEENCLOSED ENVELOF:-ALLOW UPT07 DAYS FOR RECEFPT OM VI POSTMARK CREDIT UNION Nurn6i�j� 2630 LINGLESTOWN P OST ARIL #### ####6640 HARRISBURG PA 17110-3666 Che°P.box to indl,;Ilte ❑ ttzollldd..c,MN. "back of Nis coupon llrt�:Total Mitilmd AMOUNT OF PAYMENT ENCLOSED ertt Due atei� 12/08/13 $106.85 $25.00 01/01/14 E 29 DNA G HALL 1 S LOCUST ST MAKE CHECK PAYABLE TO: SHIREMANSTOWN PA 17011-6733 1.11 ,1 its,111 111 11111111 If it,lill III,,I HIL 118,11111,11 I'll] POSTMARK CREDIT UNION PO BOX 4519 CAROL STREAM IL 60197-4519 19 : 4184 9200 0002 6640 00002500 00010685 1 QW) P6STMARK VISA C RED IT U N I ON EDNA G HALL Account Number:######0####6640 Statement Closing Date: December 08, 2013 J —t jransactions Reference Number Amount Trans Date Post Date CC'Code I' 11/25 11126 5499 24625673330207952600327 E 10 SORB INC 105,85 0 DO-592-8534 NY 2013rotali"'ear"ro Date Total Fees Charged In 2013 $2,51 Total Interest Charged in 2013 $0.00 �-!!!!erectqp-a-rge.9alculation/Plan Level Information, Plan Description----, ial;n—ce—iub Pe iodic nual Percentage Ending Balance i Interest Rate —F ate Rate(APR)2 Charge CURRENT PURCHASES G $0.00 09083% 10.90% $ 0.00 CASH A $0.00 09083% 10.90% $ 0.00 PREV PURCHASES G $0.00 05750% 6,90% $ 0.00 CASH A $0.00 05750% 6,90% $ 0.00 80TH ANNIVERSARY PROMOTION PURCHASES G $0.00 01500% 1.80% $ 0.00 CASH A $0.00 016" 1.800.6 $ 0.00 FEESANTEREST CHARGE $ 0.00 TOTAL 0.00% $ ODO $ 106.85 Z—M—jyii;r Method:See reveme side of Page 1 for explanation. 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